Healthcare Provider Details

I. General information

NPI: 1932765625
Provider Name (Legal Business Name): GRHS HOSPITAL PEDIATRICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2019
Last Update Date: 05/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 WINTER ST
LUCEDALE MS
39452-6603
US

IV. Provider business mailing address

PO BOX 1007
LUCEDALE MS
39452-1007
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-8181
  • Fax: 601-947-1331
Mailing address:
  • Phone: 601-947-8181
  • Fax: 601-947-1331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN MARIE RUTLEDGE
Title or Position: AO
Credential:
Phone: 601-947-1330